Metatarsus adductus, Skew foot, Club foot 성균관대학교삼성창원병원 장현정

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1 Metatarsus adductus, Skew foot, Club foot 성균관대학교삼성창원병원 장현정

2 Metatarsus adductus

3 Epidemiology and Etiology % with higher number for multiple birth Deformation and compression from intrauterine crowding or positioning Hip dysplasia?

4 Clinical evaluation On inspection Toe angles abruptly toward midline C-shaped lateral foot border Prominent styloid process of 5 th metatarsal Splay between great and 2 nd toes Deep skin cleft at medial midfoot

5 Clinical evaluation V -finger test

6 Clinical evaluation Flexibility Fixing hindfoot in neutral position Gently manipulating the midfoot and forefoot to more lateral position Classification Flexible / semiflexible or semirigid / rigid

7 Radiographic evaluation Not imperative (in newborn foot) Difficult to reproduce, esp. infant & toddler foot Age & flexibility : better prognosticating factor Confirm presence of complex deformities or presence of rearfoot compensation and should still be obtained

8 Radiographic evaluation Valuable, diagnostic, prognosticating tool Initial AP radiograph MAA FAA

9 Treatment Based on severity but controversial - Some authors advocate only observation without active intervention for mild case - Others intervene early in all severe cases or by 2 months of age, if the condition is not resolved - Other authors recommend treatment as soon as possible, especially in moderate to severe cases

10 Treatment Based on natural course of the condition - More conservative approach seems reasonable % resolve by 1 year of age - 87% resolved by 6 years of age, with only about 4 % remaining at age 16

11 Treatment Central theme of treatment 1. Early diagnosis 2. Early appropriate level of treatment aimed at complete reduction of the deformity 3. Prevention Flexibility & age

12 Treatment Mild (flexible, passively correctable) Only parental reassurance Daily passive strechting from the family (15-20 minutes / day over 3-4 weeks)

13 Treatment Moderate (semi-flexible, reducible) Stretching exercise at every diaper change Aggressive and early use of passive stretching Serial cast immobilization

14 Treatment Severe (rigid) - Excessive compensation at level of mediotarsal joint - Development of bunions, hammertoes, and others Serial casting and bracing Surgical treatment

15 Treatment Serial casting Helpful in children under 1 year of age Not to place the hindfoot in valgus Create a skew foot deformity Surgery More rigid persistent deformity after age of 5

16 Treatment Long-standing untreated or undertreated metatarsus adductus - Formation of skewfoot deformity - Very significant symptoms and less successful treatment by nonoperative means

17 Skewfoot

18 Terminology Rare deformity S-shaped foot, serpentine foot, Z-foot deformity Forefoot adduction and hindfoot valgus

19 Classification Congenital idiopathic type - Supple deformity, very little rearfoot valgus - Resolve with time Associated with syndrome or systemic disease - Diastrophic dwarfism, Osteogenesis imperfecta - Connective tissue disease (Ehlers-Danlos SD) - Rigid and difficult to treat

20 Classification Neurogenic - Cerebral palsy, Myelodysplasia - Due to muscular imbalance - Faster progression Iatrogenic - Inappropriate casting or surgical intervention in club foot or metatarsus adductus

21 Clinical evaluation From plantar aspect Weight bearing Flexibility Hip & knee ROM V-finger test : not helpful

22 Radiologic assessment AP and lateral radiograph with weight bearing

23 Treatment Controversial : no therapeutic escalation Natural history : unknown Important to evaluate clinical response to treatment Measures of therapy - Manipulation - Serial casting - Orthoses - Surgical management

24 Treatment Age and etiology Mild and flexible form Cast immobilization and shoe therapy Severe form Surgical intervention - Underlying neuromuscular condition - Affected on daily basis because of deformity

25 Club Foot

26 Termiology Talipes equinovarus Main component - Adduction & supination of forefoot - Varus of hindfoot - Equinus of subtalar joint - Internal rotation of leg

27 Pathoanatomy Embryological and fetal specimen 1. Adduction & supination of forefoot 2. Anterior extrusion of talus with increased plantar and medial inclination of talar neck 3. Medial subluxation of navicular toward madial malleolus 4. Medial subluxation of cuboid in relation to anterior end of os calcis

28 Epidemiology One of the most common congenital deformity of the musculoskeletal system Incidence : 1-4 / 1,000 live births / 1,000 hereditary factor Higher incidence in male 30-50% : only one side involved

29 Classification Postural Benign, resolve completely with stretching & cast Idiopathic True congenital clubfoot of variable severity Neurogenic As seen in spina bifida Syndromic Associated with other anomalies, often quiet rigid

30 Pathogenesis Mechanical factors such as intrauterine molding and oligohydroamnios Early developmental arrest of foot Primary germ plasm defect in talus Primary dislocation of talo-navicular joint Muscle imbalance d/t developmental neurological deficit Medical retraction fibrosis

31 Clinical evaluation On inspection Down and in appearance Smaller foot Flexible, softer heel due to hypoplastic calcaneus Concave medial border with deep skin furrow Highly convex lateral border

32 Clinical evaluation On testing Pronounced tightness of Achilles tendon with very little dorsiflexion

33 Radiographic evaluation Roughly parallel axes of talus and calcaneus

34 Treatment Started as soon as possible after birth Extrinsic (supple) type Positional or soft tissue deformity Treated by serial casting Intrinsic (rigid) type Manual reduction is impossible Eventually require surgery

35 Treatment Range of motion maintanence By passive exercise into dorsiflexion & eversion Plaster casting Attempt on all clubfoot as soon as practical Initially changed at semiweekly to weekly intervals Continue until deformity responds and corrected fully

36 Treatment Surgery Usually when child is 6-9 months of age Goal : stable, platform-like position for future ambulation Problems (1) leaving residual deformity (2) malcorrection (3) overcorrection worsen problem Persistent deformity into adulthood Unstable ankle, lateral sprain, difficulty with weight bearing

37 Where are we going in 21th century? 1) In the future, better understanding of pathogenesis of deformity A role for gene therapy in prevention? 2) In the future, intrauterine treatment that result in plantigrade foot at delivery? 3) Better clinical technique and better imaging modality accurately compare apples to apples 4) Evidence-based medicine to determine which modality produce optimal results

38 Where are we going in 21th century? 5) Patients will play more important role in determining optimal treatment outcome? 6) Use of platelet-derived factors for ligament healing Role in treatment of clubfoot? 7) New therapy modality which soften and lengthen tight ligaments and muscles? 8) Better orthosis which overcome noncompliance? 9) Cost of applying these advances?

39 Thank you for attention

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